Study the Strut: Gait Changes in Dogs: Cased Based Analysis Mike Thoesen, DVM, DACVS th Ave NE, Shoreline, WA (206)

Transcription

1 Study the Strut: Gait Changes in Dogs: Cased Based Analysis Mike Thoesen, DVM, DACVS th Ave NE, Shoreline, WA (206) September 17 th, 2017 Copyright 2015 Animal Surgical Clinic of Seattle. All rights reserved.

2 Types of Gait Analysis Subjective analysis o Visual observation o No special equipment o Multi-observer variability

3 Types of Gait Analysis Objective analysis o Specialized equipment o Kinematic analysis o Force plate analysis o Pressure sensing walkways

4 Subjective Gait Analysis Before analysis o Detailed history Limbs with lameness Onset and timeframe Exacerbation Previous surgeries Medical response o Static/standing exam o Complete physical exam

5 Subjective Gait Analysis Gait evaluation o Symmetrical walk and trot (best to use) o Asymmetrical canter and gallop o Observation factors Controlled flat environment with good traction View the gait at multiple angles Evaluate for subtle neurologic changes

6 Case 1 Signalment o 5 year old, F/S, German Shepherd History o 1 ½ to 2 year progressive right hind limb gait change o NSAID s lead to no improvement o The owner does not perceive her as painful

7 Gait Analysis

8 Questions to ask yourself o Neurologic vs orthopedic? o Which limb or limbs? o Does activity or speed of gait exacerbate the changes? o What does it look like from the side?

9 Case 1

10 Case 1 Physical exam findings o Spinal reflexes and proprioception WNL o No perceivable discomfort o Tight muscle/fibrous band palpated over the caudal medial thigh

11 Gracilis Muscle Contracture o Most commonly seen in German Shepherds 3-7 years of age o Often associated in combination with the semitendinosus muscle o Progressive weight-bearing abnormality that is non-painful o Jerking type of gait with hyperflexion of the tarsus and internal rotation of the metatarsus o Repeated strain?

12 Gracilis Muscle Contracture Normal anatomy o Origin pelvic symphysis o Insertion cranial border of the tibia and tuber calcanei Contracture anatomy o Cranial limb advancement o Tibia internally rotates

13 Gracilis Muscle Contracture Treatments and Prognosis Surgery o No long-term benefit? Conservative management o Non-painful o Reaches a static state o No medications have been beneficial o Stem cells/platelet-rich plasma give me some PROOF

14 Gracilis Muscle Contracture

15 Case 2 Signalment o 9 year old, M/C, Beagle History o Waxing waning gait change over 3-4 weeks o NSAID s and tramadol use lead to mild improvement o The owner perceives him as painful and stiff o No other concurrent medical conditions

16 Case 2

17 Case 2 Physical exam findings o Extreme neck stiffness o Delayed proprioception in all limbs o Neurologic reflex abnormalities Patellar reflex hyperreflexia Forelimb withdrawal incomplete Caudal cervical localization (C 6 -T 2 )

18 Differential Diagnosis - (C 6 -T 2 ) o Wobbler syndrome (cervical spondylopathy) o Inflammatory/infectious Granulomatous Meningoencephalitis (GME) most common spinal region Meningitis Discospondylitis o Fibrocartilaginous emboli (FCE) o Neoplasia o Intervertebral disc disease o Trauma - fractures

19 Caudal Cervical Lesion Front limbs o Lower motor neuron Decreased muscle tone Hyporeflexia Rapid muscle atrophy Hind limbs o Upper motor neuron Maintained muscle tone Hyperreflexia Slow muscle atrophy

20 Imaging Results C 7 -T 1 disc extrusion

21 Caudal Cervical Disc Extrusion Treatment

22 Caudal Cervical Lesion

23 Case #3 Signalment: o 8 year old o F/S o Brittany Spaniel History: o Acutely lame on the left front limb three months ago but it mostly resolved within a few days. The last two months noticed a abnormal gait with no response to NSAID s.

24 Case #3

25 Physical exam findings Case #3

26 Infraspinatus Muscle Contracture Anatomy o Origin Caudolateral scapula o Insertion Lateral greater tubercle of the humerus o Action Abduct the shoulder Lateral rotation

27 Infraspinatus Muscle Contracture o Usually occurs in adult, sporting breed dogs o Not reported in cats o Usually associated with an acute event o Radiographs help rule out other disorders o Medical management is not effective o Surgical treatment is releasing the infraspinatus tendon o Excellent prognosis

28 Infraspinatus Muscle Contracture

29 Case #4 Signalment o 2 year old, F/S, German Shepherd History o Acute left hind limb changes o NSAID s use lead to no improvement o The owner perceives her as more dysfunctional than painful

30 Case #4

31 Physical exam o Spinal reflexes within normal limits o Hyperflexion of the tarsus with the stifle in extension o Swelling over the common calcaneal tendon Case #4

32 Case #4

33 Calcaneal Tendon Avulsion

34 Calcaneal Tendon Anatomy Common calcaneal tendon o Biceps femoris o Gracilis o Semitendinosus o Gastrocnemius o Superficial digital flexure

35 Calcaneal Tendon Avulsion Treatment o Surgical repair only proven therapy o Prolonged splinting/bracing postoperative o 70-90% success

36 Partial Calcaneal Tendon Avulsion

37 Look a likes of a Calcaneal Tendon Avulsion

38 Look a likes of a Calcaneal Tendon Avulsion

39 Look a likes of a Calcaneal Tendon Avulsion

40 Plantar Tarsal Instability

41 Plantar Tarsal Instability Treatment o Partial tarsal arthrodesis o Very good to excellent surgical outcome

42 Case #5 Signalment o Tippy, 10 year old, F/S, DSH History o 4-5 week history of not wanting to use her hind limbs properly. o They had recently moved to a new house without carpets. o She seemed much worse after the vacuum scared her and she slipped on the wood floors.

43 Case #5 Previous diagnostics Thoracolumbar radiographs

44 Case #5 Previous therapies o Onsior (Robenacoxib) 6mg PO q24hr for 3 days o Tramadol 12.5mg PO q8-12hr o She showed no improvement on either therapy

45 Case #5

46 Case #5 Physical exam o T/P/R within normal limits o BCS 7/9 5.4kg o Pulses and thoracic auscultation within normal limits Neurologic exam o Spinal reflexes within normal limits o No conscious proprioception deficits o Cranial nerves - within normal limits

47 Differentials Neurogenic o Inflammatory - most common FIP (51%) Bacterial myelitis (16%) Cryptococcosis (9%) Unknown (8%) Toxoplasmosis (6%) Eosinophilic meningomyelitis (5%) Idiopathic poliomyelitis (5%) o Neoplastic o Intervertebral disc disease o Ischemic myelopathy (Marioni-Henry K: Feline spinal cord disease, Vet Clin Small Anim 40: , 2010)

48 Differentials Neurogenic Orthopedic o Bilateral stifle disease Cranial cruciate ligament disease Patellar luxation o Bilateral hip disease Capital physeal dysplasia/fractures Vascular o Saddle thrombus Metabolic o Diabetic neuropathy

49 Case #5 Orthopedic exam - Bilateral grade II/IV medial patellar luxations

50 Patellar luxations in cats o Medial is most common o I-IV grades o Surgical correction based off Severity of signs Grade of luxation o The main stay of surgery is bony corrections Tibial tuberosity transpositions Trochlear recession

51 Case #5 8 weeks postoperative

52 Nocita Aratana o Bupivacaine liposome injectable suspension o Released from the multivesicular liposomes over a period of time (72 hours) o Labeled for postoperative cranial cruciate ligament surgery pain management o Labeled for use in dogs only.

53 Nocita Clinical use instructions o Maximum dose 0.3mg/kg (0.4ml/kg) o Can be diluted 1:1 ratio 0.9% NaCl o Soft tissue injection only Other potential uses?

54 Nocita Advantages o Another modality of pain management o Minimal to no side effects o It clinically works Disadvantage o Cost

55 Questions???

56 THANK YOU! Mike S. Thoesen, DVM, DACVS th Ave NE, Shoreline, WA (206) Copyright 2015 Animal Surgical Clinic of Seattle. All rights reserved.